A reassessment is performed which re-evaluates client functioning, health and psychosocial status; identifies changes since the initial or most recent assessment; and determines new or ongoing needs.
Time Requirement: Comprehensive Case Management Comprehensive Reassessment required 180 days after completion of Initial Comprehensive Assessment. Thereafter, every 180 days at minimum, or sooner if client circumstances change significantly.
Time Requirement: Supportive Case Management Brief Reassessment required 180 days following completion of the Brief Intake/Assessment and every subsequent 180 days for active case management clients, or sooner if client circumstances change significantly.
Time Requirement: AIDS Day Health Care Program (ADHCP) Required 90 days after completion of Initial Comprehensive Assessment and every 90 days thereafter.
Time Requirement: If client entered care through HIV Medical Services:
- Brief Reassessment yearly, for those not actively engaged in case management.
- Brief Reasssessment every 180 days for active case management clients, or sooner if client circumstances change significantly.
|
In Comprehensive Case Management programs
- Each Comprehensive Reassessment includes:
- Updated personal information
- current contact and identifying information
- emergency contact
- confidentiality concerns
- household members
- insurance status
- other health and social service providers, including other case management providers.
- Updated client health history, health status, and health-related needs outlined in Initial Comprehensive Assessment, including but not limited to:
- HIV disease progression
- tuberculosis
- hepatitis
- sexually transmitted diseases
- other medical conditions
- OB/GYN, including current pregnancy status
- medications and adherence
- allergies to medications
- dental care
- vision care
- home care
- current health care providers, engagement in and barriers to care
- clinical trials
- complementary therapy.
- Updated client status and needs related to:
- nutrition
- financial resources and entitlements
- housing (including home visit to assess living situation)
- transportation
- support systems
- identification of children and separate assessment of children's needs
- identification of collaterals
- determination of collaterals needing case management assessment and services
- parenting needs
- partner notification needs
- HIV disclosure status/issues
- alcohol use/drug use/smoking
- mental health
- domestic violence
- legal needs (e.g., health care proxy, living will, guardianship arrangements, parole/probation status, landlord/tenant disputes)
- activities of daily living
- knowledge, attitudes, and beliefs about HIV disease; current risk behaviors; and prevention of transmission
- employment/education.
- Additional informatoin:
- other agencies serving client and collaterals
- brief narrative summary
- name of person completing assessment and date of completion
- supervisor signature and date, indicating review and approval.
- The case manager has primary responsibility for the Comprehensive Reassessment and meets face-to-face with the client at least once during the reassessment process.
- Unless exempt, programs providing Comprehensive Case Management conduct a home visit during the Comprehensive Reassessment process.
- The Comprehensive Reassessment is documented in the case record on forms developed or approved by the AIDS Institute.
- Documentation includes appropriate releases, including Authorization for the Release of HIV Confidential Information in accordance with Article 27F, and other releases for information as required by applicable law.
- Case Management Policies and Procedures include guidelines for conducting the Comprehensive Reassessment, staff responsible for performing it, and supervisory oversight of the reassessment process.
In Supportive Case Management programs
- Each Brief Reassessment includes:
- Client's presenting needs.
- Updated client information in the following areas:
- contact and identifying information
- emergency contact
- confidentiality concerns
- household memebers
- insurance status
- other health and social service providers, including other case managers.
- A re-evaluation of the client's status and needs regarding:
- food/clothing
- financial/benefits
- housing
- transportation
- legal
- substance use
- mental health
- domestic violence
- HIV diseases and other medical concerns
- prevention of transmission and secondary prevention
- support system.
- The case manager has primary responsibility for the Brief Reassessment. The Brief Reassessment is performed in person or by phone.
- In Supportive Case Management, the Brief Reassessment is documented in the chart. A new or clearly updated Brief Intake/Assessment form, a form developed for the purpose, or a detailed progress note covering the areas of information listed in numbers 1(1) through 1(3) above may be used as documentation of a Brief Reassessment.
- Documentation includes appropriate releases, including Authorization for the Release of HIV Confidential Information in accordance with Article 27F, and other releases for information as required by applicable law.
- Case Management Policies and Procedures include guidelines for conducting the Brief Reassessment, staff responsible for performing it, and supervisory oversight.
|